Provider Demographics
NPI:1245751718
Name:FUENTES, EVELYN ANGELICA
Entity Type:Individual
Prefix:
First Name:EVELYN
Middle Name:ANGELICA
Last Name:FUENTES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10762 KESWICK ST
Mailing Address - Street 2:
Mailing Address - City:SUN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91352-4606
Mailing Address - Country:US
Mailing Address - Phone:818-823-4090
Mailing Address - Fax:
Practice Address - Street 1:8142 SUNLAND BLVD
Practice Address - Street 2:
Practice Address - City:SUN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:91352
Practice Address - Country:US
Practice Address - Phone:818-306-4254
Practice Address - Fax:818-582-8836
Is Sole Proprietor?:No
Enumeration Date:2017-07-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374700000X
CAR4718101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374700000XNursing Service Related ProvidersTechnician
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)